Please Take Part in an International
Study to Find Vitiligo Genes
Do you have Vitiligo, or have you had it in the past? Or, does someone in your family have Vitiligo? If so, would you or they be willing to take part in a major research project on Vitiligo?
We have put together an international team of scientists to find the genes that cause Vitiligo. We don’t know what most ofthese genes are yet, and so we need additional patients and families to narrow our search. Our goal is to discover the causes of Vitiligo, and the other autoimmune diseases that are often associated with Vitiligo—thyroid disease, rheumatoid arthritis, psoriasis, pernicious anemia, lupus, Addison disease, and adult-onset insulin-dependent diabetes. Please give serious consideration to participating. Our long-term goal is to better understand the causes of Vitiligo and these related diseases, so as to develop better treatments and even approaches to prevention of these diseases altogether.
The first step in your participating is to fill out the attached questionnaire and mail or email it to us. We will then contact respondents that might be appropriate to the study to get further information and arrange for a saliva (spit) sample or, occasionally, a small blood sample. We thank you in advance for your help, and we look forward to hearing from you."
Richard A. Spritz, M.D.
Professor and Director
Human Medical Genetics Program
MS-8300, RC-1/P18
University of ColoradoDenver
12800 East 19th Avenue
Aurora, CO80045USA

USAVitiligo Family Study Questionnaire

We are carrying out a study to better understand Vitiligo and related autoimmune diseases and to eventually discover the genes that cause these disorders. We would appreciate your help. This form should be filled in by (or for) one person in your family that has Vitiligo. Please write clearly. If there is not enough room for your answers, please continue on a sheet of paper and attach it to this form.

NOTE: All personal information will be kept in confidence and will not be used for anything other than this study.

IMPORTANT: When we ask about brothers, sisters, parents, etc., we are referring to "blood" relatives (not relatives by marriage or adoption). Similarly, "brothers/sisters" means people with the same mother and father, not half-brothers, etc. Half-brothers and half-sisters should be indicated specifically.

  1. If you are the person with Vitiligo, please go to question 2. If you are filling out this form for someone else (in which case, from question 3 onwards, "you" refers to the person with Vitiligo), please enter their name here:

2.Please enter your name, address, telephone number and email address.

EMAIL address:

  1. What is your age? _____, sex? _____, and age when Vitiligo first appeared? _____
  1. How much of your skin would you say is affected by Vitiligo at present? (check one)

___ Up to 25% ___ Up to 26-50% ___ 51-75% ___ Up to 76-100%
5.Would you be willing to take part in this project by giving a small saliva sample? ______

6.For each brother or sister willing to take part in the project, please provide the following: (If they have never had Vitiligo, write "N")

Name / Phone Number / Age / Sex / Age When Vitiligo First Appeared

7.Is your mother alive? ______If so, would she be willing to give a saliva sample? ______

8.Is your father alive? ______If so, would he be willing to give a saliva sample? ______

9.Who else in your family has Vitiligo? Please give their age when it first appeared, if known. [For example: mother (10), son (5), father's sister (teens)]

______

______
______
10. Please briefly describe any special medical conditions that you or any of your relatives have, such as diabetes (specify insulin-requiring versus non-insulin requiring and approximate age of onset), pernicious anemia, psoriasis, rheumatoid arthritis, thyroid problems, lupus, Addison's disease, etc. (do not include infections, cancer or injuries)

Condition / Who has condition(e.g., aunt, me, etc.)

11. How many brothers do you have? _____ How many sisters? _____

12. How many brothers does your mother have? _____ How many sisters? _____

13.How many brothers does your father have? _____ How many sisters? _____

14.How many children do you have? _____

15.If your child has Vitiligo, is their other parent willing to take part in this study? _____

16.Has that parent ever had Vitiligo? _____ Has anyone else in that parent's family ever had Vitiligo? _____

17.Please check whichever of the following ethnic groups fits you best:

___ White/Caucasian / ___ African-American/African / ___ Hispanic
___ Native American / ___ Indian/Pakistani / ___ Middle-Eastern
___ Asian / ___ Mixed Race / ___ Other

18.If you answered 'mixed race' or 'other', please explain:

19. What is your eye color and natural hair color?

Eye Color:Hair Color:

If there is any other information you think may be useful to us, particularly your vitiligo treatment history and response to treatment, please add it here or on another page:

Thank you very much for your help.

Once you have completed the form, please return it to:

Richard A. Spritz, M.D.
Professor and Director

Human Medical Genetics Program

MS-8300, RC-1/P18

University of ColoradoDenver

1200 East 19th Avenue

Aurora, CO80045USA

Email: